The All-Out Assault On Diabetes

Imagine your doctor says he plans to increase your oral medication to control your diabetes. You do not like taking pills. Should you:
A. Not rock the boat with your doctor and agree to take the increased dosage?
B. Agree, but keep taking the same number of pills?
C. Try to discuss another option with your doctor?

Monica Peek, MD, assistant professor of internal medicine at the University of Chicago, believes the best answer for long-term health and happiness is C. But she knows that low-income African Americans with diabetes will often, for a variety of reasons, agree with the doctor and then ignore the advice. Peek has spent hours leading classes with patients from this vulnerable group. They role-play talking to their doctor, critique each other as they practice, and give a debriefing on whether they could ever truly feel comfortable taking an active approach with a physician.

The classes are part of a new program to chip away at the disparities in diabetes among low-income African Americans. The gap is huge. The prevalence of diabetes on the South Side is 19.3 percent, compared with an average prevalence in Chicago of about 7 percent. African American neighborhoods in Chicago have five times the rate of diabetes-related leg amputations as primarily white neighborhoods do.

Three years ago, about 40 people at the University of Chicago Medical Center with expertise in nutrition, cultural tailoring, communication, quality improvement, and even community organizing launched an effort to close this gap. They were prepared to tackle multiple factors that exacerbate diabetes outcomes on the South Side. Among them are unhealthy eating habits, limited safe places to exercise, food insecurity and less access to health care.

Their first move was to get out of the hospital.

The group created teams at six community health clinics to focus on improving diabetes care. They led patients on field trips to local grocery stores to practice making smart food choices. The physicians were constantly on the radio, at health fairs, in churches and high school gymnasiums, educating South Siders about diabetes. Still, the Medical Center team ran into challenges from all sides.

“The economic factors of people choosing between food and medications don’t account for all of the disparities,” Peek said. “There is racial and cultural baggage that creeps into clinical encounters between doctors and poor African American patients.” As an example of this long history of bias, Peek cites a famous 1999 study from Georgetown University in which cardiologists were found to offer better care to men over women who complained of heart problems, and to white patients over black patients.

“People who have had bad interactions with the health care system may delay treatment until their condition is dire,” Peek said. Some say they are afraid of being experimented on, that they don’t trust doctors to do right by them, or that they dislike the perceived power imbalance of being in a doctor’s office.

Peek said she was surprised to learn how some low-income African Americans view the doctor-patient relationship. A woman told her that she gets agitated when she goes to a doctor’s office and hears, “What brings you here today?” — she thinks the doctor is saying, “Why are you sitting in front of me when I’m so busy?”

“It was eye-opening to me,” Peek said. “This is how we teach our medical students to serve their patients, but it can actually alienate low-income African Americans.”

Believing that she could change this mistrust through education, Peek started a weekly class with diabetes patients.

The class used questions like the one about a doctor increasing medication dosages to discuss how patients could be more involved during meetings with their physician. “We culturally tailored the curriculum for our audience and made it more hands-on and more entertaining. We also made it more appropriate for lower literacy levels,” Peek said. Instead of written handouts, there were games and videos.

The class was so popular and the exit interviews so encouraging that Peek has repeated the entire 10-week course three additional times. Class participants have not only visited a food pantry that stocked healthy foods and joined public fitness centers, but their glucose monitoring, foot care, and glucose control improved significantly.

Marshall Chin, MD, professor of medicine and an internist at the University of Chicago, focused his efforts on improving not the patients, but their medical care. “If a physician sees a patient for 15 minutes, three times a year, and tells her to exercise and lower her sugar intake without helping her figure out how, it’s a set-up for failure,” he said.

Quality improvement teams worked at the six community health clinics on the South Side, trying to improve their diabetes care and their use of programs and support systems within each patient’s community. “The patient spends most of his life at home, in his community, in his workplace. Without additional support systems outside the clinic, we’re sunk,” he said.

Chin believes that medical providers may understand the challenges that poor black patients face in caring for themselves, but the health care system is not currently set up to address these problems. Part of the solution is to connect diabetes patients to the resources in her community. For example, a physician can write a “fitness prescription” for a patient, to give her six months of free access to a Chicago Park District gym.

The community health center staff is also developing “food prescriptions” that give patients access to free or discounted healthy food, and trying to connect their patients to a popular community center with cooking demonstrations and a food pantry.

“People sometimes feel overwhelmed with the challenges of diabetes on the South Side, but there are tremendous strengths in this community,” Chin said.

The early data from the program are promising. Since the program started three years ago, 4,000 people who were using the Emergency Department for primary care have been connected to a medical home.

The results of the first three years of this all-out assault against diabetes, called “Early Lessons From an Initiative on Chicago’s South Side to Reduce Disparities in Diabetes Care and Outcomes,” are published in the January issue of Health Affairs.

The program has funding for seven years from the Merck Company Foundation and the National Institutes of Health, and will continue to grow as the data show improvements in diabetes outcomes.

“Diabetes is a huge problem that hurts a lot of people and takes up a lot of resources. But until now, the solutions we have seen haven’t been powerful enough,” Chin said. “Finally, we have a model showing that we can make a difference.”